#325 Topical Anal Fissure Treatments – getting to the bottom of it
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- Five systematic reviews of RCTs in last 10 years.1-5 Focusing on most recent. Adjunctive treatments usually unclear (often fiber or dietary advice). Healing mostly defined as determined on exam or patient reported.
- Calcium channel blockers (example diltiazem 2% ointment):
- Healing (4 RCTs, 372 patients):
- At 6 weeks, 78% versus 42% (placebo), number needed to treat (NNT)=3 (calculated by PEER).1
- Other systematic reviews found similar.2,3
- Healing (4 RCTs, 372 patients):
- Nitroglycerins (example nitroglycerin 0.2-0.4% ointment):
- Healing (17 RCTs, 1063 patients):
- At 8 weeks,1 63% versus 38% (placebo), NNT=4.
- Other systematic reviews found efficacy ~50% versus 35% (placebo).2,3
- Healing (17 RCTs, 1063 patients):
- Calcium channel blockers versus nitroglycerins:
- Healing (11 RCTs, 770 patients):
- At 8 weeks, 79% versus 65% nitroglycerin.1
- Similar in other systematic reviews,3-5 but only statistically different in 1 review.3
- Headache (10 RCTs, 590 patients):
- 7% versus 56% nitroglycerin.1
- Healing (11 RCTs, 770 patients):
- Limitations:
- Many systematic reviews included pediatrics, did not include all RCTs and had suboptimal statistical analysis; many RCTs unblinded and considered high risk of bias.
- Vitamin E:
- 1 RCT, 160 patients, topical vitamin E or topical nitroglycerin twice daily.6 At 8 weeks:
- Healing: 86% versus 66% nitroglycerin, NNT=5.
- Stopping due to headache: 0 versus 18% nitroglycerin.
- Limitations: Patients unblinded, nitroglycerin possibly underdosed, unknown IU/g of vitamin E.
- 1 RCT, 160 patients, topical vitamin E or topical nitroglycerin twice daily.6 At 8 weeks:
- Most fissures are at the midline. Other locations may indicate secondary cause (example Crohn’s disease) and should be investigated.7
- Guidelines recommend topical calcium channel blockers or topical nitroglycerins.8,9
- Botox and surgery are options for treatment failure, but fecal incontinence possible.9
- Cost (~8 weeks):
- Compounded topical calcium channel blocker/nitroglycerin: ~$60/30g.10
- Commercially available vitamin E ointment = ~$10/50g.11
Interesting information on efficacy of vit E
good information
The vit E study was unblinded! Why even include such a poor study?
simple but useful
I like this quick summary, relevant to a patient I just saw yesterday.
Never knew that Vit E is used for anal fissure
topical calcium channel blockers appear most effective
vitamin E ointment is the cheapest